Registration Form. City: State: Zip: Birthdate: Marital Status: M S W D. Patient Employer: Occupation: Employer Address: Emp.

Transcription

1 Registration Form Patient Information Name: Address: SS#: Phone: City: State: Zip: Sex: F M Birthdate: Marital Status: M S W D Patient Employer: Occupation: Employer Address: Emp. Phone: Whom may we thank for referring you? Emergency Contact: Phone: Primary Insurance Person responsible for account: Birthdate: Relationship to patient: SS#: Address(if different than patient): City: State: Zip: Person responsible Employed by: Business Address: Phone: Insurance Company: ID# Group# Additional Insurance Person responsible for account: Relationship to patient: SS#: Address(if different than patient): City: State: Zip: Person responsible Employed by: Business Address: Phone: Insurance Company: ID# Group#

2 Medical History Date: Patient Name: Date of Birth: Primary Physician: Phone: Date Last Seen: What Type of Problems are you having with your feet? Past Medical History:(Please check any of the following conditions you currently have or have had in the past.) Diabetes Heart Attack Burning in feet Chemical Dependency Cancer Blood clots Numbness in feet Bleeding Disorders Stroke Liver Disease Lung Disease Rheumatoid Arthritis Gout Stomach Ulcer Sickle Cell Anemia Degenerative Arthritis HIV+ Heartburn/Reflux Thyroid Disease Seizures Anemia High Blood Pressure Glaucoma High Cholesterol Alcoholism Kidney Disease Cataracts Psychiatric Disorders Asthma Heart Disease Depression Hepatitis Heart Murmur Pacemaker Are you pregnant? Are you currently being seen by a pain management center? Please list any other conditions that we should know about: Medications:(List Medications that you are currently taking.) Family History: Has any of your immediate family had any of the following: Cancer Heart Disease Stroke Diabetes Arthritis Melanoma High Blood Pressure Allergies:(Please list medicines you have had an allergic reaction to in the past) Are you allergic to: Tape Iodine IVP Dye Shellfish Latex Other Social History: Do you use Tobacco? How Much per day? How many Years? Do you Drink Alcohol? How many drinks per week? Do you use any recreational drugs?/what kind? Past Surgical History:

3 Assignment: Medicare Signature on File I request that payment of authorized Medicare benefits be made on my behalf to Alpine Podiatry Center, PA for any services furnished me by the listed provider/supplier. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I request payment of authorized Medicare benefits be made to this provider and also authorize any holder of medical information about me to release to the below named Medicare insurer any information needed to determine benefits payable for services from this provider. I understand my signature below requests that payment be made and authorizes release of medical information necessary to pay the claim. My signature authorizes releasing of the information to the insurer or agency, electronically, or by mail. In Medicare assigned cases, this office agrees to accept the "charge determination" of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-insurance, and non-covered services. Co-insurance and the deductible are based upon the "charge determination" of the Medicare carrier. Patient Name (please print) X Date Patient Signature X Patient Medicare Number

4 Patient Financial Policy We are dedicated to providing the best possible care and service to you and regard your complete understanding our financial policies as an essential element of your care and treatment. If you have any questions, please discuss them with our front office staff or supervisor. As our patient, you are responsible for all authorizations/referrals needed to seek treatment in this office. Unless other arrangements have been made in advance by you, or your health insurance carrier, payment for office services are due at the time of service. We will accept VISA, MasterCard, Discover, cash or check. Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you if you assign the benefits to the doctor. In other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for payment. We have made prior arrangements with insurers and other health plans to accept an assignment of benefits. We will bill those plans with which we have an agreement and will only require you to pay the co-pay/co-insurance/deductible at the time of service If you have insurance coverage with a plan with which we do not have a prior agreement, we will prepare and send the claim for you on an unassigned basis. This means your insurer will send the payment directly to you. Therefore, all charges for your care and treatment are due at the time of service. All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be "not covered," or you do not have an authorization, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized services; however, you remain responsible for charges to any service rendered. Patients are encouraged to contact their plans for clarification of benefits prior to services rendered. You must inform the office of all-insurance changes and authorization referral requirements. In the event the office is not informed, you will be responsible for any charges denied. For most services provided in the hospital, we will bill your health plan. Any balance due is your responsibility. There are certain elective surgical procedures that we require pre-payment. You will be informed in advance if your procedure is one of those. In that event, payment will be due one week prior to the surgery. Past due accounts are subject to collection proceedings. All fees including, but not limited to collection fees, attorney fees and court fees shall become your responsibility in addition to the balance due this office. There is a service fee of $25.00 for all returned checks. Your insurance company does not cover this fee. Printed Name: Date: Signature:

5 Christopher H. Crabtree, DPM Catherine A. Paukovitz, DPM Notice of Privacy Practices Alpine Podiatry Center complies with HIPAA regulations to keep your medical information private and secure. We require you to sign that you have been given this guarantee. If you would like a detailed copy of our HIPAAcompliance policy, please ask a staff member and we will be glad to give you a personal copy. I acknowledge that I have been provided the opportunity to review the privacy policy of this practice: Name: Signature: Date: If you think that we may have violated your privacy right, contact Dr. Christopher Crabtree at: Alpine Podiatry Center P.O. Box 337 Fort Mill, SC You may also submit a written complaint to the U.S. Department of Health and Human Services at the following address: 200 Independence Avenue, S.W. Washington, D.C We will not retaliate in any way if you chose to file a complaint. 430 S. Herlong Ave. # Ben Casey Dr. #133 Rock Hill, SC Fort Mill, SC Phone: Phone: Fax: Fax: